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Focus | Linking TB and the Environmentand theLinkingTB Environmentne of the world’s leading killers, tuberculosis (TB) is nearly as old as humanityitself; fossilized evidence of this lethal infection has beenAn Overlooked Mitigation StrategyOfound in a Homo erectus skeleton half a million years old. Butlook to a modern hospital in a developed country, and you’d be hard pressed tofind more than a few cases. Historically, TB is a disease of the poor. Most of the2–3 million people who die of the disease every year come from the developingworld or from poor, urban neighborhoods in wealthier nations. For centuries, TBhas been linked anecdotally with environmental risk factors that go hand-in-handwith poverty: indoor air pollution, tobacco smoke, malnutrition, overcrowdedliving conditions, and excessive alcohol use. Now scientists are presentingconvincing evidence to back these associations, leading some TB experts to arguethat control programs must confront underlying risk factors to limit the spread ofthe disease.Tim Dirven/Panos PicturesA man suffering from TB arrives at a hospital in Mymensingh, Bangladesh.Bangladesh has the sixth greatest TB burden in the world.Environmental Health Perspectives •VOLUME116 | NUMBER 11 | November 2008A 479
Focus | Linking TB and the EnvironmentAccording to the World Health Organization (WHO), more than 9 million new cases ofTB are diagnosed annually, 55% of them in Asia and 31% in Africa, placing TBsecond only to HIV/AIDS in terms of the global burden of infectious disease. TBcontrol strategies adopted by the WHO and other organizations emphasize clinicalsolutions in the form of drugs, vaccines, and access to health care. But despitethe success of these programs, TB incidence and mortality aren’t falling rapidlyenough to meet WHO targets, and in some areas, particularly in parts of Asia andthroughout sub-Saharan Africa, they continue to climb. “Better treatment isessential, but if we want to affect longer-term trends in the epidemic we willalso have to deal with risk factors,” asserts Eva Rehfuess, a scientist with theWHO Department of Public Health and Environment. “But doing that won’t be easy.Social and environmental interventions aren’t usually delivered or funded by thehealth sector, so that means we all have to work with other sectors, in particularhousing, energy, and education, to move them forward.” Emerging evidence suggestssuch interventions could yield big benefits. In a report published online 3October 2008 ahead of print in The Lancet, Majid Ezzati and colleagues at theHarvard School ofPublic Health predict that by 2033 TB incidence rates in parts of China could be14–52% lower if tobacco smoking and indoor air pollution from traditional cookingstoves are eliminated. These reductions assume that 80% of the population alreadyhas access to optimal treatments for TB; the benefits would be even greater amongthose without such access, says Ezzati, an associate professor of global healthand environmental health.The Current SituationOne-third of the world’s population is thought to be infected with various strainsof Mycobacterium tuberculosis, the microbe that causes TB, but only 5–10% ofinfected individuals will develop active disease. Among those with latentinfections, which are nontransmissible, M. tuberculosis exists in a mysteriousdormant state. Precisely why the bacterium favors latency is unknown. Immunityappears to play a role, given that dormant TB often converts to active diseasewhen immune systems falter, for instance, as a consequence of HIV/AIDS. But someTB strains might also favor latency as an evolved trait that fosters survival,says Christopher Dye, an epidemiologist in the WHO Stop TB Department and coauthorof “Expanding the Global Tuberculosis Control Paradigm: The Role of TB RiskFactors andEstimated Incidence of New TB Cases as of 2006Source: WHO. 2008. Global tuberculosis control 2008: surveillance, planning,financing. Geneva: World Health Organization; p. 20.Social Determinants,” a chapter in the forthcoming WHO report Priority PublicHealth Conditions: From Learning to Action on Social Determinants of Health. “It’spossible that latency evolved as a mechanism to avoid extinction when humanpopulations were small and isolated,” he explains. “There are lots of ideas, butour understanding of the bacteria is primitive, and we haven’t come close toexplaining the basic facts yet.” TB drugs are a two-edged sword, says TommieVictor, a professor of health sciences at Stellenbosch University in SouthAfrica’s Western Cape Province. They destroy the bacterium, but can also selectfor resistant bacteria against which those drugs are then ineffective. In the1970s, the drugs had the upper hand, and TB seemed to be in decline. But fundingand interest in TB control programs also declined, says Victor, and for thefollowing 20 years no systematic monitoring of drug resistance was carried out.The situation changed dramatically with the arrival of HIV/AIDS in the 1980s, when
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